Validation of cause-of-death statistics in urban China

BACKGROUND: National vital registration systems are the principal source of cause specific mortality statistics, and require periodic validation to guide use of their outputs for health policy and programme purposes, and epidemiological research. We report results from a validation of cause of death statistics from health facilities in urban China. METHODS: 2917 deaths from health facilities located in six cities in China constituted the study sample. A reference diagnosis of the underlying cause was derived for each death, based on expert review of available medical records, and compared with that filed at registration. Sensitivity, specificity and positive predictive value were computed for specific causes/cause categories according to the International Classification of Diseases (ICD), including analyses based on quality of evidence scores for each cause. Patterns of misclassification by the registration system were studied for individual causes of death. RESULTS: The registration system had good sensitivity in diagnosing cerebrovascular disease and several site specific cancers (lung, liver, stomach, colorectal, breast and pancreas). Sensitivity was average (50-75%) for some major causes of adult death in China, namely ischaemic heart disease (IHD), chronic obstructive lung disease (COPD), diabetes, and liver and kidney diseases, with compensatory misclassification patterns observed between several of them. Sensitivity was particularly low for hypertensive disease. CONCLUSIONS: Although diagnostic misclassification is not uncommon in urban death registration data, they appear to balance each other at the population level. Compensating misclassification errors suggest that caution is required when drawing conclusions about particular chronic causes of adult death in China. Investment is required to improve the quality of cause attribution for health facility deaths, and to assess the validity of cause attribution for home deaths. Periodic assessments of the quality of cause of death statistics will enhance their usability for health policy and epidemiological research.     

Global and regional cause-of-death patterns in 1990.

Demographic estimation techniques suggest that worldwide about 50 million deaths occur each year, of which about 39 million are in the developing countries. In countries with adequate registration of vital statistics, the age at death and the cause can be reliably determined. Only about 30-35% of all deaths are captured by vital registration (excluding sample registration schemes); for the remainder, cause-of-death estimation procedures are required. Indirect methods which model the cause-of-death structure as a function of the level of mortality can provide reasonable estimates for broad cause-of-death groups. Such methods are generally unreliable for more specific causes. In this case, estimates can be constructed from community-level mortality surveillance systems or from epidemiological evidence on specific diseases. Some check on the plausibility of the estimates is possible in view of the hierarchical structure of cause-of-death lists and the well-known age-specific patterns of diseases and injuries. The results of applying these methods to estimate the cause of death for over 120 diseases or injuries, by age, sex and region, are described. The estimates have been derived in order to calculate the years of life lost due to premature death, one of the two components of overall disability-adjusted life years (DALYs) calculated for the 1993 World development report. Previous attempts at cause-of-death estimation have been limited to a few diseases only, with little age-specific detail. The estimates reported in detail here should serve as a useful reference for further public health research to support the determination of health sector priorities.     

Estimating cause-specific mortality from community- and facility-based data sources in the United Republic of Tanzania: options and implications for mortality burden estimates

OBJECTIVE: To compare mortality burden estimates based on direct measurement of levels and causes in communities with indirect estimates based on combining health facility cause-specific mortality structures with community measurement of mortality levels. METHODS: Data from sentinel vital registration (SVR) with verbal autopsy (VA) were used to determine the cause-specific mortality burden at the community level in two areas of the United Republic of Tanzania. Proportional cause-specific mortality structures from health facilities were applied to counts of deaths obtained by SVR to produce modelled estimates. The burden was expressed in years of life lost. FINDINGS: A total of 2884 deaths were recorded from health facilities and 2167 recorded from SVR/VAs. In the perinatal and neonatal age group cause-specific mortality rates were dominated by perinatal conditions and stillbirths in both the community and the facility data. The modelled estimates for chronic causes were very similar to those from SVR/VA. Acute febrile illnesses were coded more specifically in the facility data than in the VA. Injuries were more prevalent in the SVR/VA data than in that from the facilities. CONCLUSION: In this setting, improved International classification of diseases and health related problems, tenth revision (ICD-10) coding practices and applying facility-based cause structures to counts of deaths from communities, derived from SVR, appears to produce reasonable estimates of the cause-specific mortality burden in those aged 5 years and older determined directly from VA. For the perinatal and neonatal age group, VA appears to be required. Use of this approach in a nationally representative sample of facilities may produce reliable national estimates of the cause-specific mortality burden for leading causes of death in adults.     

Impact of misclassification on measures of cardiovascular disease mortality in the Islamic Republic of Iran: a cross-sectional study

OBJECTIVE: To assess the extent and pattern of misclassification of death from non-specific diagnoses emanating from the Iranian death registration system, and to correct the data for health policy and planning. METHODS: Detailed medical records for 1426 hospital deaths classified to seven ill-defined or vague causes of death were reviewed by trained physicians, who then completed standard death certificates. Underlying causes of death from the review were compared with the cause assigned in registration data. FINDINGS: The probable underlying pattern of causes of death in the Islamic Republic of Iran is substantially different to that suggested by the death registration system. About 88% of 582 cases with non-specific diagnoses at ages 15-69 years were reassigned to various specific causes including ischaemic heart disease (33%), stroke (13%) and injuries (10%). A similar pattern of misclassification is apparent for 738 deaths at older ages (70 years and over), with 46% being reassigned to ischaemic heart disease and stroke. CONCLUSION: A significant proportion of deaths in the Iranian death registration system are being classified to cause groups of little relevance to epidemiological research or health policy. Reassignment of these deaths would increase the proportion of deaths from ischaemic heart disease and cerebrovascular diseases each by 32%, diabetes mellitus by 68% and chronic lower respiratory diseases by 73%. Substantial changes to procedures for diagnosing causes of death are urgently required if registration data are to effectively guide health policies and programmes in the Islamic Republic of Iran.     

Validation of verbal autopsy procedures for adult deaths in China

BACKGROUND: Vital registration of causes of death in China is incomplete with poor coverage of medical certification. Information on the leading causes of mortality will continue to rely on verbal autopsy (VA) methods. A new international VA form is being considered for data collection in China, but it first needs to be validated to determine its operating characteristics. METHODS: Detailed medical records and clinical evidence for 3290 deaths (mostly adults) among residents of six cities representative of the urban Chinese population were reviewed by a panel of physicians and coded by experts to establish a reference underlying cause of death. Independently, families of the deceased were interviewed using a structured symptomatic questionnaire and a separate death certificate was prepared for each matching case (2102). Validity of the VA procedure was assessed using standard measurement criteria of sensitivity, specificity, and positive predictive value. RESULTS: VA methods perform reasonably well in identifying deaths from several leading causes of adult deaths including stroke, several major cancer sites (lung, liver, stomach, oesophagus, and colorectal), and transport accidents. Sensitivity was less satisfactory in detecting deaths from several causes of major public health concern in China including ischaemic heart disease, chronic obstructive pulmonary disease, diabetes, and tuberculosis, and was particularly poor in diagnosing deaths from viral hepatitis, hypertension, and kidney diseases. CONCLUSIONS: VA is an imprecise tool for detecting leading causes of death among adults. However, much of the misclassification generally occurs within broad cause groups (e.g. CVD, respiratory diseases, and liver diseases). Moreover, compensating patterns of misclassification would appear to suggest that, in urban China at least, the method yields population-level cause-specific estimates that are reasonably reliable. These results suggest the possible utility of these methods in rural China, to back up the low coverage of medical certification of cause of death owing to poor access to health facilities there.     

Unintentional injury mortality in India, 2005: Nationally representative mortality survey of 1.1 million homes

ABSTRACT: BACKGROUND: Unintentional injuries are an important cause of death in India. However, no reliable nationally representative estimates of unintentional injury deaths are available. Thus, we examined unintentional injury deaths in a nationally representative mortality survey. METHODS: Trained field staff interviewed a living relative of those who had died during 2001-03. The verbal autopsy reports were sent to two of the130 trained physicians, who independently assigned an ICD-10 code to each death. Discrepancies were resolved through reconciliation and adjudication. Proportionate cause specific mortality was used to produce national unintentional injury mortality estimates based on United Nations population and death estimates. RESULTS: In 2005, unintentional injury caused 648 000 deaths (7% of all deaths; 58/100 000 population). Unintentional injury mortality rates were higher among males than females, and in rural versus urban areas. Road traffic injuries (185 000 deaths; 29% of all unintentional injury deaths), falls (160 000 deaths, 25%) and drowning (73 000 deaths, 11%) were the three leading causes of unintentional injury mortality, with fire-related injury causing 5% of these deaths. The highest unintentional mortality rates were in those aged 70 years or older (410/100 000). CONCLUSIONS: These direct estimates of unintentional injury deaths in India (0.6 million) are lower than WHO indirect estimates (0.8 million), but double the estimates which rely on police reports (0.3 million). Importantly, they revise upward the mortality due to falls, particularly in the elderly, and revise downward mortality due to fires. Ongoing monitoring of injury mortality will enable development of evidence based injury prevention programs.     

Can regional variation in "avoidable" mortality be explained by deaths outside hospital? A study from Sweden, 1987-90.

STUDY OBJECTIVE: This study aimed to calculate the proportion of deaths outside hospital in Sweden for some conditions for which the acute medical management may be important to the outcome and to analyse whether the proportion of deaths outside hospital can explain regional variations in mortality from these causes of death. DESIGN: The place of death was registered on all death certificates in Sweden during the period 1987-90. The proportion of deaths outside hospital was calculated at the national level for selected causes of death. Variation in cause-specific mortality among the 26 administrative health areas in Sweden was analysed. Death rate ratios were calculated with standardisation for age and sex using the national rate as standard. The correlation between the proportion of deaths outside hospital in each health area and the cause specific mortality irrespective of place of death was calculated. For areas with a significantly high death rate the ratios for mortality outside hospital as well as in hospital were analysed in order to decide which component of mortality represented a high mortality risk. SETTING AND PARTICIPANTS: All death registration in Swedish citizens and other residents in Sweden aged under 70 years between 1987 and 1990 which gave diabetes, asthma, ischaemic heart disease, cerebrovascular diseases, or ulcer of the stomach or duodenum as the underlying cause of death. MAIN RESULTS: For asthma (58%) and ischaemic heart disease (54%), most deaths occurred outside hospital. For most causes of death, however, no correlation was found among the health areas between the proportion of deaths outside hospital and the SMR for mortality irrespective of the place of death. A high death rate was associated with a high proportion of deaths outside hospital, for diabetes in one area in the north of Sweden (Norrbotten) and for ulcer of the stomach and duodenum in one large municipality (Göteborg). CONCLUSIONS: The high proportion of deaths outside hospital at the national level for some of the conditions studied suggests that in-depth studies of the process preceding death and the functioning of medical care are needed. In most cases, however, no evidence was found that regional variation in mortality could be explained by death outside hospital. The results for diabetes in Norbotten and ulcer of stomach and duodenum in Göteborg indicate that in-depth studies on the quality of care are required.     

Mortality trends in Fiji

Objectives: Mortality level and cause of death trends are evaluated to chart the epidemiological transition in Fiji. Implications for current health policy are discussed. Methods: Published data for infant mortality rate (IMR), life expectancy (LE) and causes of death for 1940–2008 were assessed for quality, and compared with mortality indices generated from recent Ministry of Health death recording. Trends in credible mortality estimates are compared with trends in proportional mortality for cause of death. Results: IMR declined from 60 deaths (per 1,000) in 1945 to below 20 by 2000. IMR for 2006–08 is estimated at 18–20 deaths per 1,000 live births. Excessive LE estimates arise by imputing from the IMR using inappropriate models. LE increased, but has been stable at 64 years for males and 69 years for females since the late 1980s and early 1990s respectively. Proportional mortality from diseases of the circulatory system has increased from around 20% in the 1960s to more than 45%. Extensive variation in published mortality estimates was indentified, including clearly incompatible ranges of IMR and LE. Conclusions: Mortality decline has stagnated. Relatively low IMR and proportional mortality trends suggest this is largely due to chronic diseases (especially cardiovascular) in adults. Implications: Reconciliation of mortality data in Fiji to reduce uncertainty is urgently needed. Fiji's health services and donor partners should place continued and increased emphasis on effective control strategies for cardiovascular disease.     

Who dies of what? A comparative analysis of mortality conditions in developed countries around 1987

The developed countries are often viewed as being relatively homogeneous in terms of health conditions. This is not the case, however. Whilst the overall level of life expectancy in these countries (73.7 years) is well in excess of that observed in the majority of developing countries, there are nonetheless very substantial differences in health status among and between the developed countries. Female life expectancy is typically 6-8 years longer than that of males. The gap in life expectancy between Japan and some countries of Northern Europe, on the one hand, and the nations of Eastern Europe on the other, is of the same order of magnitude. Of the 11 million deaths reported in the developed countries each year, roughly 5.5 million or almost exactly 50% are attributable to cardiovascular diseases. Of these deaths, 2.4 million are coded to ischaemic heart disease and 1.5 million to stroke (cerebrovascular disease). Cancer (all forms) accounts for 2.3 million deaths (21%), 500,000 of which are due to lung cancer alone. External causes of death claim 750,000 lives each year in the developed countries, with suicide and motor-vehicle accidents each accounting for around 180,000 deaths. This pattern of mortality, when viewed in conjunction with the epidemiological evidence about the principal risk factors associated with these causes of death, strongly suggests that national health-for-all strategies must continue to emphasize individual health consciousness as the primary means of achieving national health goals.     

Poverty, time, and place: variation in excess mortality across selected US populations, 1980-1990

STUDY OBJECTIVE: To describe variation in levels and causes of excess mortality and temporal mortality change among young and middle aged adults in a regionally diverse set of poor local populations in the USA. DESIGN: Using standard demographic techniques, death certificate and census data were analysed to make sex specific population level estimates of 1980 and 1990 death rates for residents of selected areas of concentrated poverty. For comparison, data for whites and blacks nationwide were analysed. SETTING: African American communities in Harlem, Central City Detroit, Chicago's south side, the Louisiana Delta, the Black Belt region of Alabama, and Eastern North Carolina. Non-Hispanic white communities in Cleveland, Detroit, Appalachian Kentucky, South Central Louisiana, Northeastern Alabama, and Western North Carolina. PARTICIPANTS: All black residents or all white residents of each specific community and in the nation, 1979-1981 and 1989-1991. MAIN RESULTS: Substantial variability exists in levels, trends, and causes of excess mortality in poor populations across localities. African American residents of urban/northern communities suffer extremely high and growing rates of excess mortality. Rural residents exhibit an important mortality advantage that widens over the decade. Homicide deaths contribute little to the rise in excess mortality, nor do AIDS deaths contribute outside of specific localities. Deaths attributable to circulatory disease are the leading cause of excess mortality in most locations. CONCLUSIONS: Important differences exist among persistently impoverished populations in the degree to which their poverty translates into excess mortality. Social epidemiological inquiry and health promotion initiatives should be attentive to local conditions. The severely disadvantageous mortality profiles experienced by urban African Americans relative to the rural poor and to national averages call for understanding.     

Mortality attributable to tobacco use in Canada and its regions, 1998

OBJECTIVES: The purpose of this report is to calculate 1998 smoking attributable mortality (SAM) and to explore whether SAM estimates have changed from the late 1980s to the late 1990s. METHODS: Using the data from the National Population Health Survey and the Canadian Mortality Database, a modified Smoking-Attributable Mortality, Morbidity and Economic Cost (SAMMEC) method was applied to estimate national and regional smoking-attributable mortality for 1998. FINDINGS: The results indicate that in 1998, 30,230 men and 17,351 women died as a result of both active and passive smoking, including 96 children under the age of 1. This includes 1,107 Canadians who died from both lung cancer and ischemic heart disease attributable to environmental tobacco smoke. The total of 47,581 deaths represents an increase of 9,224 deaths since 1989, with females accounting for 6,531 of these increased deaths. The increase in female mortality is divided between cancers (2,452), cardiovascular diseases (1,646), and respiratory diseases (2,283). In 1998, the top causes of adult smoking-related deaths were lung cancer (13,951 deaths), ischemic heart disease (9,289 deaths) and chronic airways obstruction (6,457 deaths). CONCLUSION: Cigarette smoking remains the number one preventable cause of death in Canada and its impact on the health of Canadians continues to be an unacceptable burden.     

Epidemiologic transition interrupted: a reassessment of mortality trends in Thailand, 1980-2000

BACKGROUND: In the late 1980s and early 1990s a generalized HIV epidemic affected Thailand which was relatively well controlled by an intensive national campaign by the mid 1990s. The extent to which the epidemic has slowed or possibly reversed the epidemiological transition in Thailand is relatively unknown. METHODS: Under-five mortality rates (U5MR) were determined from various sources and weighted least squares regression conducted to determine U5MR over the years 1980-2000. Direct and indirect estimates of the completeness of death registration were used to estimate mortality levels in those aged more than 5 years for the 1980-90 and 1990-2000 periods. Life tables were constructed using the various estimates to determine changes in life-expectancy between the two time periods. RESULTS: U5MR in Thailand is estimated to have been 58/1000 live births in 1980, declining to 30 in 1990 and to 23 in 2000. The vital registration system clearly underestimates U5MR. Successive surveys of Population Change (SPC) imply coverage of death registration improving from 75-77% in 1985-86 to 95% in 1995-96, partly due to a reliance on self-reported registration in the latter survey. In contrast, the General Growth Balance-Synthetic Extinction Generations (GGB-SEG) method suggests coverage worsening from 78-85% in 1980-90 to 64-72% in 1990-2000. Life tables based on SPC adjustments show continued declines in female, and to a lesser extent, male adult mortality with corresponding increases in life-expectancy at birth of around 6 years for both sexes from 1980-90 to 1990-2000. In contrast, the indirect adjustments suggest a substantial increase in male adult mortality with female adult mortality unchanged; life expectancy decreased by 4 years for males and was only marginally higher in females. CONCLUSION: Given the conflicting evidence a definitive assessment of mortality change in Thailand between 1980 and 2000 is difficult to make. Indirect adjustments, based on demographic methods point to a major reversal in mortality decline among males, and a slowing in females. If adult mortality registration has declined, and given the continued under-registration of infant and child deaths, remedial measures are urgently required if the mortality system is to better inform and monitor health development in Thailand.     

河北省国家疾病监测点恶性肿瘤死亡率分析

目的了解河北省国家疾病监测点恶性肿瘤死亡流行病学特征,为制定恶性肿瘤防治策略提供依据。方法死因编码执行《国际疾病分类第十版（ICD-10）》标准,全省8个国家疾病监测点人口资料和死亡个案资料全部使用DeathReg软件进行数据录入、审核、汇总和统计分析。结果2006年河北省国家疾病监测点恶性肿瘤粗死亡率76.14/10万,标化死亡率50.83/10万,居全死因顺位第二位,恶性肿瘤死因顺位前4位是肺癌、食管癌、胃癌、肝癌,男性、女性均以肺癌死亡率最高;城市肺癌死亡率最高,农村为食管癌。恶性肿瘤主要发生于35岁以上人群,并随年龄增长死亡率上升。结论肺癌、食管癌、胃癌、肝癌是危害河北省国家疾病监测点居民健康的主要恶性肿瘤,应继续加强恶性肿瘤防治工作。     

Contemporary patterns of Pacific Island mortality

BACKGROUND: The Pacific Island countries are at different stages of the demographic and epidemiological transitions. The availability of accurate and current mortality data is of vital importance for priority setting in health. Available mortality data generally underestimate death rates among both children and adults. In many Pacific Island populations, little is reliably known about levels and causes of death, particularly among adults. METHODS: The results of two comprehensive approaches to obtaining mortality estimates are reported. First, a systematic review of available life expectancy and infant mortality information reported by countries from 1990 onwards was undertaken and evaluated with respect to quality, and a final "best estimate" was established. Methods were based on registered deaths and indirect demographic methods. The second approach consisted of a demographic evaluation of vital registration data for completeness, with death rates adjusted accordingly, or where vital registration was not available, the application of new model life table methods to generate life tables from estimates of child mortality, as used by the World Health Organisation (WHO). RESULTS: This analysis reveals substantial uncertainty about mortality conditions in Pacific Island populations. In some countries, life expectancy variations of 10 years or more were recorded in the 1990s, depending on the source. Best approaches suggest that life expectancy (at birth) varied considerably, from levels of around 55-60 years in some Melanesian and Micronesian states to levels above 70 years in low-mortality countries. The principal issues with regard to uncertainty around mortality levels include underenumerated vital registration data; annual stochastic fluctuations in mortality in small populations; errors in the imputation of adult mortality from infant and childhood rates; implausible results from indirect demographic methods; use of possibly inappropriate model life tables to adjust death data or for indirect methods; and inadequately described and implausible projections. The WHO model life table method based on adjusted vital registration generally yielded results similar to those suggested by an evaluation of published data, with some exceptions, which are further discussed. CONCLUSIONS: This study indicates the urgent need to improve infrastructure, training, and resources for routine mortality estimation in many Pacific Island countries in order to better inform and evaluate health and public policy.     

Trends in Causes of Adult Deaths among the Urban Poor: Evidence from Nairobi Urban Health and Demographic Surveillance System, 2003–2012

What kills people around the world and how it varies from place to place and over time is critical in mapping the global burden of disease and therefore, a relevant public health question, especially in developing countries. While more than two thirds of deaths worldwide are in developing countries, little is known about the causes of death in these nations. In many instances, vital registration systems are nonexistent or at best rudimentary, and even when deaths are registered, data on the cause of death in particular local contexts, which is an important step toward improving context-specific public health, are lacking. In this paper, we examine the trends in the causes of death among the urban poor in two informal settlements in Nairobi by applying the InterVA-4 software to verbal autopsy data. We examine cause of death data from 2646 verbal autopsies of deaths that occurred in the Nairobi Urban Health and Demographic Surveillance System (NUHDSS) between 1 January 2003 and 31 December 2012 among residents aged 15 years and above. The data is entered into the InterVA-4 computer program, which assigns cause of death using probabilistic modeling. The results are presented as annualized trends from 2003 to 2012 and disaggregated by gender and age. Over the 10-year period, the three major causes of death are tuberculosis (TB), injuries, and HIV/AIDS, accounting for 26.9, 20.9, and 17.3 % of all deaths, respectively. In 2003, HIV/AIDS was the highest cause of death followed by TB and then injuries. However, by 2012, TB and injuries had overtaken HIV/AIDS as the major causes of death. When this is examined by gender, HIV/AIDS was consistently higher for women than men across all the years generally by a ratio of 2 to 1. In terms of TB, it was more evenly distributed across the years for both males and females. We find that there is significant gender variation in deaths linked to injuries, with male deaths being higher than female deaths by a ratio of about 4 to 1. We also find a fifteen percentage point increase in the incidences of male deaths due to injuries between 2003 and 2012. For women, the corresponding deaths due to injuries remain fairly stable throughout the period. We find cardiovascular diseases as a significant cause of death over the period, with overall mortality increasing steadily from 1.6 % in 2003 to 8.1 % in 2012, and peaking at 13.7 % in 2005 and at 12.0 % in 2009. These deaths were consistently higher among women. We identified substantial variations in causes of death by age, with TB, HIV/AIDS, and CVD deaths lowest among younger residents and increasing with age, while injury-related deaths are highest among the youngest adults 15–19 and steadily declined with age. Also, deaths related to neoplasms and respiratory tract infections (RTIs) were prominent among older adults 50 years and above, especially since 2005. Emerging at this stage is evidence that HIV/AIDS, TB, injuries, and cardiovascular disease are linked to approximately 73 % of all adult deaths among the urban poor in Nairobi slums of Korogocho and Viwandani in the last 10 years. While mortality related to HIV/AIDS is generally declining, we see an increasing proportion of deaths due to TB, injuries, and cardiovascular diseases. In sum, substantial epidemiological transition is ongoing in this local context, with deaths linked to communicable diseases declining from 66 % in 2003 to 53 % in 2012, while deaths due to noncommunicable causes experienced a four-fold increase from 5 % in 2003 to 21.3 % in 2012, together with another two-fold increase in deaths due to external causes (injuries) from 11 % in 2003 to 22 % in 2012. It is important to also underscore the gender dimensions of the epidemiological transition clearly visible in the mix. Finally, the elevated levels of disadvantage of slum dwellers in our analysis relative to other population subgroups in Kenya continue to demonstrate appreciable deterioration of key urban health and social indicators, highlighting the need for a deliberate strategic focus on the health needs of the urban poor in policy and program efforts toward achieving international goals and national health and development targets.     

Estimation of life‐years gained and cost effectiveness based on cause‐specific mortality

Cost‐effectiveness analysis is usually based on life‐years gained estimated from all‐cause mortality. When an intervention affects only a few causes of death accounting for a small fraction of all deaths, this approach may lack precision. We develop a novel technique for cost‐effectiveness analysis when life‐years gained are estimated from cause‐specific mortality, allowing for competing causes of death. In the context of randomised trial data, we adjust for other‐cause mortality combined across randomised groups. This method yields a greater precision than analysis based on total mortality, and we show application to life‐years gained, quality‐adjusted life‐years gained, incremental costs, and cost effectiveness. In multi‐state health economic models, however, mortality from competing causes is commonly derived from national statistics and is assumed to be known and equal across intervention groups. In such models, our method based on cause‐specific mortality and standard methods using total mortality give essentially identical estimates and precision. The methods are applied to a randomised trial and a health economic model, both of screening for abdominal aortic aneurysm. A gain in precision for cost‐effectiveness estimates is clearly helpful for decision making, but it is important to ensure that ‘cause‐specific mortality’ is defined to include all causes of death potentially affected by the intervention. Copyright © 2010 John Wiley & Sons, Ltd.     

A comparison of two cause-of-death classification systems for deaths among women of reproductive age in Menoufia, Egypt

Mortality data ascertained from sources other than a death registration system can validate the accuracy of the system, but this information is rarely obtained. Data on 1979 deaths among reproductive age women were collected in the 1981-1983 Reproductive Age Mortality Survey (RAMOS) in the governorate of Menoufia, Egypt, and compared with data on these deaths as recorded by the Egyptian death registration system. Although the distribution of the causes of death were similar, there were substantial differences between classification systems for deaths due to particular causes. Over half of the deaths classified differently by the systems were those assigned to circulatory disease on the death certificate. In contrast, there was a high rate of agreement between systems in the classification of trauma deaths. About half (52.4%) of cancer deaths had the same site-specific cancer diagnosis assigned by RAMOS. The percentage of deaths assigned to maternal causes was three times higher in RAMOS (19.2%) than on death certificates (6.1%). Reported mortality rates for this often-preventable cause of death have been substantially underestimated in national death registration systems. Such underreporting masks the need for additional prenatal care and maternal health programmes.     

Non-communicable disease mortality rates using the verbal autopsy in a cohort of middle aged and older populations in Beirut during wartime, 1983-93

STUDY OBJECTIVES: Health priorities in middle to low income countries, such as Lebanon, have traditionally been assumed to follow those of a "typical" developing country, with a focus on the young and on communicable diseases. This study was carried out to quantify the magnitude of communicable and non-communicable disease mortality and to examine mortality pattern among middle aged and older populations in an urban setting in Lebanon. DESIGN AND PARTICIPANTS: A representative cohort of 1567 men and women (>/=50 years) who had participated in a cross sectional multi-dimensional health survey in Beirut, Lebanon in 1983 and were followed up 10 years later. Vital status was ascertained and causes of death were obtained through verbal autopsy. RESULTS: Total mortality rates were estimated at 33.7 and 25.2/1000 person years among men and women respectively. In both sexes, the leading causes of death were non-communicable, mainly circulatory diseases (60%) and cancer (15%). For all cause mortality, men had significantly higher risk than women (age adjusted rate ratio, RR=1.42, 95% confidence intervals (CI) = 1.16, 1.72) especially at younger ages. Except for cerebrovascular diseases, renal problems and injuries attributable to falls and fractures, men were also at higher cause specific mortality risk than women, in particular, for ischaemic heart disease (RR = 2.24, 95% CI = 1.62, 3.12). Comparison with earlier death certificate data in Lebanon and current estimates from other regions in the world showed the magnitude of cardiovascular disease over time. CONCLUSIONS: The results from this first cohort study in the Arab region show, in contrast with popular perception, a mortality pattern more like a developed country than a developing one. Strategies of public health activities, in particular for countries in transition, need to be continuously re-assessed in light of empirical epidemiological data and other health indicators for evidence-based decision making.     

Availability and quality of cause-of-death data for estimating the global burden of injuries

Objective

To assess the availability and quality of global death registration data used for estimating injury mortality.

Methods

The completeness and coverage of recent national death registration data from the World Health Organization mortality database were assessed. The quality of data on a specific cause of injury death was judged high if fewer than 20% of deaths were attributed to any of several partially specified causes of injury, such as “unspecified unintentional injury”.

Findings

Recent death registration data were available for 83 countries, comprising 28% of the global population. They included most high-income countries, most countries in Latin America and several in central Asia and the Caribbean. Categories commonly used for partially specified external causes of injury resulting in death included “undetermined intent,” “unspecified mechanism of unintentional injury,” “unspecified road injury” and “unspecified mechanism of homicide”. Only 20 countries had high-quality data. Nevertheless, because the partially specified categories do contain some information about injury mechanisms, reliable estimates of deaths due to specific external causes of injury, such as road injury, suicide and homicide, could be derived for many more countries.

Conclusion

Only 20 countries had high-quality death registration data that could be used for estimating injury mortality because injury deaths were frequently classified using imprecise partially specified categories. Analytical methods that can derive national estimates of injury mortality from alternative data sources are needed for countries without reliable death registration systems.     

Mortality from leading causes by education and race in the United States, 2001

BACKGROUND: Low educational attainment is a marker of socioeconomic status that correlates strongly with higher death rates from many conditions. No previous studies have analyzed national data to measure the number of deaths associated with lower education among working-aged adults (25-64 years) by race or ethnicity. Furthermore, no previous studies have examined comprehensively the relationship of education to cause-specific and all-cause mortality in the three largest racial or ethnic groups in the United States using national data. METHODS: Age-standardized, race/ethnicity-specific death rates from all causes and the 15 leading causes were measured among men and women aged 25-64 years by level of education based on U.S. national mortality data in 2001. The total number of deaths that potentially could be avoided among people aged 25-64 years was estimated by applying the mortality rates among college graduates (within each 5-year category of age, gender, and race/ethnicity) to each of the less-educated subpopulations. All analyses were performed in 2007. RESULTS: Nearly half (48%) of all deaths among men aged 25-64 years (white, black, and Hispanic), and 38% of all deaths in women would not have occurred in this age range if all segments of the population experienced the death rates of college graduates. Black men and women had the highest death rates from all causes combined and from many specific causes at nearly all levels of education, and the largest average life years lost before age 65 years. However, the total number of deaths associated with low education status was not confined to any single racial group. About 161,280 deaths in whites, 40,840 deaths in blacks, and 13,162 deaths in Hispanics in this age range were associated with educational disparity. CONCLUSIONS: Potentially avoidable factors associated with lower educational status account for almost half of all deaths among working-aged adults in the U.S.; these deaths are not confined to any single racial or ethnic group. These findings highlight the need for greater attention to social determinants of health.